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Herman & Wallace Blog

Risk Factors for Postpartum Coccyx Pain

Pelvic rehabilitation providers commonly treat a variety of conditions associated with peripartum pelvic girdle dysfunction. This list of conditions includes coccyx pain, and a recent study aimed to identify risk factors which may lead to coccyx pain in the postpartum period. Dr. Jean-Yves Maigne, who is well known for providing foundational research on the topic of coccyx pain, and colleagues completed a case series of 57 postpartum women presenting to a specialty coccydynia clinic. Dynamic x-rays were taken to assess mobility of the coccyx, and data about delivery methods were collected. (A control group of 192 women were comprised of women who also presented to the clinic but who had coccyx pain from other causes.)

The authors found that the women reported immediate postpartum pain in the coccyx with sitting. Instrumentation was a common finding in regards to the patients’ deliveries. 50.8% of the deliveries utilized forceps while 7% were vacuum-assisted. An additional 12.3% of the deliveries were spontaneous and were described as “difficult.” A subluxation of the coccyx was observed in 44% of the women who developed coccyx pain after childbirth as compared to 17% of the controls. A fractured coccyx occurred in 5.3 % of the women. Body mass index (BMI) of more than 27 and having 2 or more vaginal deliveries was also associated with a higher prevalence of a subluxation of the coccyx.

Being unable to sit comfortably following childbirth could make a new parent’s life very difficult with limitations in activities such as sitting to feed the baby. Socially, being unable to sit comfortably can also limit many activities. The women in this study reported immediate tailbone pain with sitting, which can alert providers to a condition requiring both immediate and follow-up attention. Risk factors such as having a difficult delivery or use of forceps may also signal a patient history that may lead to coccyx pain.

If you are interested in learning more about managing coccyx pain, join Lila Abbate at Coccyx Pain Evaluation and Treatment in Bay Shore, NY on October 25-26! You may also be interested to learn more about treating patients during the postpartum period, in which case Care of the Postpartum Patient is right up your alley!

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Verbal Instructions and Pelvic Floor Contractions in Men

What are you saying when giving directions to men during pelvic floor muscle training, and how do those instructions affect the effectiveness of a contraction? These questions are tackled in a study that is very interesting to therapists working in pelvic dysfunction. 15 healthy men ages 28-44 (with no prior training in pelvic floor training) were instructed to complete a submaximal effort pelvic muscle contraction. Tools utilized to acquire data in the study include those below:

Assessment tool Measuring
Transperineal ultrasound displacement of pelvic floor landmarks
Surface EMG (electromyography) abdominal, anal sphincter muscle activation
Nasogastric transducer intra-abdominal pressure (IAP)
Fine wire electromyography (3 participants only) puborectalis, bulbocavernosus muscles

Participants sat upright on a plinth (backrest reclined at ~20 degrees with their knees extended). Directions for the submaximal efforts were given by telling the men to produce a level 3/10 effort with 10 being a maximal contraction. The men were instructed to hold the contraction for 3 seconds, and they were given 10 seconds rest between each of the 4 contractions using different verbal cues. (This series of 4 contractions was repeated with randomization for verbal cues, with a 2 minute rest in-between.) Verbal instructions were intended to target specific contractile tissues as described below- some of this theory could be validated via the fine wire EMG.

Verbal cue Targeting
"tighten around the anus" anal sphincter
"elevate the bladder" puborectalis
"shorten the penis" striated urethral sphincter
"stop the flow of urine" striated urethral sphincter, puborectalis

Displacement, IAP, and abdominal/anal EMG were compared for the different verbal instructions. The greatest dorsal displacement of the mid-urethra and striated urethral sphincter activity was noted with the instruction to "shorten the penis." "Elevate the bladder" encouraged the greatest increase in abdominal EMG and IAP, while "tighten around the anus" induced the greatest anal sphincter activity. Displacement of pelvic landmarks correlated with EMG readings of the muscles thought to produce the targeted movement. The authors conclude that the therapist's choice of verbal instructions can influence the muscle activation and urethral movement in men. They suggest "shorten the penis" and "stop the flow of urine" for optimal activation of the striated urethral sphincter. They also point out the fact that by using the fine wire EMG and correlating muscle activation to observations with the transperineal ultrasound, the study validates the use of the less invasive method. If you are ready to jump into more education about male pelvic rehabilitation, join us in Denver in early August, or Seattle in November.

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How can we Quickly Make a Diagnosis of Complex Pelvic Pain Patients?

Today we get the opportunity to hear from Herman & Wallace faculty member Elizabeth Hampton PT, WCS, BCIA-PMB! Elizabeth has been kind enough to offer her insights about the diagnosis of pelvic rehabilitation patients. Join Elizabeth at Finding the Driver in Pelvic Pain this November in Houston, TX in order to learn evaluation tools for complex pelvic pain clients!

Having taught for Herman and Wallace since 2006, I have a few observations that have been consistent over the years. Clinicians want their clients to get better, so much so that they are ready to jump in to treatment before having a solid problem list and validated findings. I can understand this: after a 3 day course we have clients Monday morning at 8 a.m. who have been waiting for us to take this course so we can get them better! We had better be smart ASAP! But what do we do when we are treating symptoms rather than understanding the primary, secondary and tertiary factors in their condition?

Finding the Driver in Pelvic Pain is a course that is a foundational first step in screening the pelvic pain client. It is a great place to start. I developed the course because there was no evidence based comprehensive factors that had been established as fundamentals for screening a pelvic pain client.

The other thing I have learned after teaching Pelvic Floor Function, Dysfunction, & Treatment – Level 2B for 9 years is that the majority of clinicians who take this intermediate level course cannot perform a precise vulvar and intrapelvic muscle mapping assessment. Close your eyes and pretend you are mapping a client’s left iliococcygeus: can you place your finger in the proper orientation and know 100% you would be palpating it? Indeed, this takes training and repetition. Internal pelvic floor muscle mapping is a key part of the Finding the Driver screening system.

What do you do when you have a pelvic pain client on your schedule and a 45-60 minute slot? How do you screen findings and get the plan of care within such a short period of time? Finding the Driver is a comprehensive pelvic floor and musculoskeletal screening to rule in or rule out drivers of the pain from all sources including spine, pelvic ring, neural entrapment, intra-articular hip, load transfer, biomechanics and motor control. There is a clear flow to the screening process and an emphasis on how to organize that information, as we know with pelvic pain, it is the copious amount of information that is the challenge. We have two case studies with either participants or clients of a local Physical Therapist who come in and we go through the entire screen, prioritize treatment and provide that treatment during the course. The participants walk away with clear clinical reasoning for their treatment and prioritization of treatment as primary, secondary, and so on. The goal of the course is to help the clinician sort through the extraordinary amount of information we gather on our pelvic pain client and organize it in a way that we can explain to the client as well as create our plan of care. Treatment is not linear, as we are frequently treating many aspects at the same time. However being able to organize the information is key in designing that plan of care. For example, with a prone knee bend that reproduces labial pain, we find that the genitofemoral nerve is causing referred pain. However that referral may be due to constipation, irritable bowel, inguinal entrapment due to hernia surgery, intra-abdominal adhesions due to endometriosis, osteitis pubis or facilitated segment at the upper lumbar spine. How do we tease that out? How do you sequence nerve glide, visceral work, soft tissue mobilization, joint mobilization and dietary components for colonic motility? The treatment with all of those components are very different indeed. Finding the Driver is a hands on course with systematic screening tools and, with case studies, we go through treatments appropriate to that client. The focus is on what we, as physical therapists, can do to understand the drivers.

At the last Finding the Driver course in Milwaukee, WI, we had two case studies in pelvic pain. One client reported chronic psoas and adductor tightness with deep left sided pelvic pain. As a professional aerialist, she was extraordinarily flexible and demonstrated positions of tightness that concerned her, which included lateral splits with her hips in slight horizontal abduction and extension (yes, yikes!) When she reported that her adductor felt tight in this position, I explained it was because it was trying to keep her leg attached to her body! She was 9/9 on the Beighton scale and had severe multidirectional instability in her hips, impaired load transfer through her pelvis, respiratory dysfunction with efforts at pelvic floor and transverse abdominis contraction, as well as repeated choice of activities that were profoundly provoking. Interestingly, she was better at load transfer during handstands (bilateral or unilateral) vs. in standing and we discussed her course of treatment addressing the primary, secondary and tertiary aspects of her condition. Another client had severe labial pain, and despite multiple abdominal and intravaginal surgeries, her symptom onset was 4 months prior. She certainly had visceral, postural, joint restrictions, movement dysfunction and many other factors. But her primary driver was a labral tear in her hip and she needed surgery. After surgery, her pain was 100% resolved and in her post op rehab, the other factors could be addressed.

It is safe to say that it can be difficult to perform a comprehensive screen in 45-60 minutes on ALL clients. We all know that many of our clients need to tell their story and because of fear or previous negative history, we may choose as clinicians how to spend that session to best honor the needs of the client. That being said, Finding the Driver is a course which provides a solid start in differential diagnosis so you can drill down into more specifics on subsequent visits.

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Visceral Therapy in Rehabilitation

Visceral therapy is increasingly used by manual therapists, and research continues to emerge that attempts to explain the underlying mechanisms of the techniques. A study published in the Journal of Bodywork & Movement Therapies in 2012 reports on the effects of visceral therapy on pressure pain thresholds. Osteopathic visceral mobilization was applied to the sigmoid colon in 15 asymptomatic subjects. Pressure pain thresholds were measured at the L1 paraspinal muscles and 1st dorsal interossei before and after intervention. Pressure pain thresholds at the level assessed improved significantly immediately following the visceral mobilization. The effect was not found to be systemic. Hypoalgesia, therefore, may be a mechanism by which visceral mobilization affects patients who are treated with this technique.

Another research study that aimed to assess the effects of visceral manipulation (VM) on low back pain found that the addition of VM to a standard physical therapy treatment approach did not provide short term benefits. However, when the 64 patients were reassessed at 2, 6, and 52 weeks following treatment, the patients in the group with visceral manipulation were found to have less pain at 52 weeks. The patients were randomized into 2 equal groups and were provided physical therapy plus a placebo visceral treatment or a visceral treatment in addition to physical therapy. The authors propose that there may be long-term benefits of including visceral therapy in rehabilitation approaches.

If you would like to learn more about visceral techniques as well as theory and clinical application, check out the schedules for Ramona Horton's Visceral Mobilization 1 (VM1): The Urologic System, and Visceral Mobilization 2 (VM2): The Reproductive System. The first opportunity to take VM1 is in November in Salt Lake City and VM2 is scheduled in September in Ohio.

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Pranayama for Dysmenorrhea

Recently in the Pelvic Rehab Report blog we discussed the beneficial role of pelvic rehabilitation for symptoms of dysmenorrhea. Additional research was published this year that supports the use of pranayama for improving quality of life and pain in girls with primary dysmenorrhea. Breathing within yoga studies is a rich field, with well-defined variations in stages and kinds of breathing, techniques and postures, and use of different hand positions and breathing through the nostrils and/or mouth. The Oxford online dictionary defines pranayama as a practice coming from Hindu yoga and related to regulating the breath through specific techniques.

Pranayama

In the study, the practice of both slow pranayama (Nadi Shodhan) and fast pranayama (Kapalbhati) was instructed to the women to be completed in the mornings on an empty stomach for 10 minutes per day. Ninety unmarried young women (ages 18-25) diagnosed with primary dysmenorrhea were randomly and equally assigned to either Group A (slow pranayama) or Group B (fast pranayama). Outcomes included the Moos menstrual distress questionnaire (MMDQ), numerical pain rating pain scale, a quality of life scale "by American chronic pain association" and the assessments were administered at baseline, after the first menstrual cycle, and after the second menstrual cycle. To read more details about the methods and results, the full article can be accessed here.

Prior and recent research has also studied the effects of similar breathing techniques on cognitive functions in healthy adults and also on perceived stress and cardiovascular parameters in young healthcare students. While it may not be new to compare fast and slow pranayama techniques with health conditions, this is the first study to address pranayama's effects on symptoms of dysmenorrhea. The authors conclude that practicing slow pranayama compared to fast pranayama improved quality of life and pain scores related to dysmenorrhea. Furthermore, the authors suggest that because pranayama can decrease absenteeism and stress levels, the practice should be implemented in college students to improve quality of life.

If you are looking to learn more about pranayama and other methods of self-management of conditions including, but certainly not limited to, dysmenorrhea, come to the city-New York City- next month for Meditation for Patients and Providers instructed by faculty member Nari Clemons. It's sure to be hot in the city, so chill out indoors with Nari, and hang out at night with your new favorite colleagues that you'll meet. A benefit of this course is that not only can you learn to care better for your patients, but also for yourselves, and you deserve it.

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Women and Sex – After Cancer (Part Two)

Today we present Part II of Michelle Lyons' discussion on sex after gynecologic cancer. Michelle will be teaching a course on this topic in White Plains in August!

In Part One of this blog, I looked at the sexual health issues women face after gynecologic cancer. In Part Two, I want to explore different treatment options that we as pelvic rehab specialists can employ to help address the many implications of cancer and cancer treatment

Treatment for gynecologic cancers, including vulvar, vaginal, cervical, endometrial and ovarian cancers, may include surgery, radiation therapy, chemotherapy, and/or hormonal therapy. We know that any of these approaches can have an adverse effect on the pelvic floor, as well as systemic effects on a woman’s body. Issues can include pain, fibrosis, scar tissue adhesions, diminished flexibility, fatigue and feeling fatigued and unwell. The effects on body image should not be under-estimated either. In their paper ‘Sexual functioning among breast cancer, gynecologic cancer, and healthy women’, Anderson & Jochimsen explore how ‘…body-image disruption may be a prevalent problem for gynecologic cancer patients…more so than for breast cancer patients’. The judicious use of manual therapy and local and global exercise prescription may be excellent pathways for a women to re-integrate with her body.

Many women will have to learn to care for a new colostomy or how to catheterize a continent urostomy. A woman who has had a vulvectomy will need sensitive counselling to understand that she can still respond sexually. Patients who have had a vaginectomy with reconstruction as part of a pelvic exenteration will need extensive rehab to help them achieve successful sexual functioning. We as pelvic rehab practitioners are in a uniquely privileged position – not only can we ask the questions and discuss the options but we are licensed to be ‘hands on’ professionals, using our core skills of manual therapy, bespoke exercise advice and educating our patients about a range of issues from the correct usage of lubricants, dilators, sexual ergonomics and brain/pain science. I am in the habit of describing pelvic rehab as the best specialty in physical therapy but I think this is especially true when it comes to the junction of oncology and pelvic health. This is where we can integrate our knowledge of neuro-science, orthopaedics, the lymphatic system and pelvic health to deal with the effects of pelvic cancers and their treatment.

In Farmer et al’s 2014 paper, ‘Pain Reduces Sexual Motivation in Female But Not Male Mice’ , the authors found that ‘Pain from inflammation greatly reduced sexual motivation in female mice in heat -- but had no such effect on male mice’. Unfortunately ongoing pelvic pain is a common sequela of treatment for gynecologic cancers – reasons ranging from post-operative adhesions, post-radiation fibrosis or vaginal stenosis or genital lymphedema. It is also worth bearing in mind the ‘rare but real’ scenario of pudendal neuralgia following pelvic radiation, as discussed by Elahi in his 2013 article ‘Pudendal entrapment neuropathy: a rare complication of pelvic radiation therapy.’

The good news is that we have much to offer. Yang in 2012 (‘Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial’) showed that pelvic rehab improved overall pelvic floor function, sexual functioning and QoL measures for gynecological cancer patients. Yang’s pelvic rehab group (administered by an experience physiotherapist) displayed statistically significant differences in physical function, pain, sexual worry, sexual activity, and sexual/vaginal function. Gynecological cancer and treatment procedures are potentially a fourfold assault: on sexual health, body image, sexual functioning, and fertility. Sexual morbidity is an undertreated problem in gynecological cancer survivorship that is known to occur early and to persist beyond the period of recovery (Reis et al 2010). We have a good and growing body of evidence that pelvic rehab, delivered by skilled therapists, has the potential to address each of these issues. And perhaps, most encouraging, here is Yang’s conclusion: ‘…‘Pelvic Floor Rehab is effective even in gynecological cancer survivors who need it most.’ (Yang 2012)

Interested in learning more about the role of pelvic rehab in gynecologic cancer survivorship? Join me in White Plains in August!

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Pelvic Dysfunction in Female Cyclists

Blog by Holly Tanner

A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.

 

 


 

Examples of Research Cited
Ideas for Addressing Potential for Harm
dropped handlebar position increases pressure on the perineum and can decrease genital sensation encourage cyclists to take breaks from dropped position, either by standing up or by moving out of drops temporarily
chronic trauma can cause clitoral injury encourage cyclists to wear appropriately padded clothing, to apply cooling to decrease inflammation, and to use quality shocks or move out of the saddle when going over rough roads/terrain when able
saddle loading differs between men and women women should consider specific fit for bike saddles
women have greater anterior pelvic tilt motion is pelvic motion on bike demonstrating adequate stability of pelvis or is there a lot of extra motion and rocking occurring?
lymphatics can be harmed from frequent infections and from groin compression patients should be instructed in positions of relief from compression and in self-lymphatic drainage
pressure in the perineal area is affected by saddle design, shape female cyclists with concerns about perineal health should work with a therapist or bike expert who is knowledgeable about a variety of products and fit issues
unilateral vulvar enlargement can occur from biomechanics factors therapists should evaluate vulvar area for size, swelling, and evidence of imbalances in the tissues from side to side, and evaluate bike fit and mechanics, encouraging women to create more symmetry of limb use
genital sensation is frequently affected in cyclists, indicating dysfunction in pudendal nerve therapists should evaluate female cyclists for sensory or motor loss, establishing a baseline for re-evaluation

Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.

 

Within a pelvic rehabilitation setting, applying all orthopedic and specific pelvic rehabilitation skills is necessary for women cyclists who present with pelvic dysfunction. Because injury to the perineal area including the pudendal nerve can have negative impact on function such as bowel, bladder, or sexual health, skills in helping a patient heal from compressive or traumatic cycling injuries is very valuable. To learn more about pudendal nerve health and dysfunction, the Institute offers a 2-day course titled Pudendal Neuralgia Assessment, Treatment and Differentials: A Brain/Pain Approach. This course is offered next in Salt Lake City in April, so sign up soon!

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Overactive Bladder and the Role of the Pelvic Floor

Relaxation Training for UI

How does pelvic floor muscle function differ in women with symptoms of overactive bladder compared to symptomatic women? A study completed by Knight and colleagues included determining if pelvic floor muscle surface electromyography (EMG) and pelvic floor muscle (PFM) performance were different among these groups. Scores regarding anxiety, life stress, and quality of life were assessed. Symptoms of overactive bladder can include urinary urgency, frequency, nocturia, and leakage of urine. Subjects in this study had "dry" overactive bladder, meaning that the patients did not experience leakage associated with the urgency.

28 women with urinary urges and frequency were age-matched to 28 asymptomatic controls. Participants completed the Beck Anxiety Inventory, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Recent Life Changes Questionnaire. Surface EMG was utilized to assess pelvic floor muscle function. Results of the study included that women with urinary urgency and frequency had significantly more anxiety than women in the control group. Surface EMG measures (pathway vaginal sensor was used with self-placement) were not significantly different for ability to contract or relax the PFM. Scores on the PFIQ and the RLCQ were significantly higher for women with overactive bladder. The authors conclude that, although a causative relationship could not be made between overactive bladder and anxiety, there exists a relationship between the two conditions.

Another interesting study which compared interventions of yoga versus mindfulness for women who have symptoms of urinary urge incontinence found that mindfulness-based stress reduction was effective for reducing urinary incontinence episodes whereas yoga was not. This study followed a pilot directed by the same primary investigator which showed similar positives results of mindfulness training on urinary urge incontinence.

What are the clinical questions we may draw from these research reports? Does anxiety cause urinary urgency and frequency, or does urinary urgency and frequency cause anxiety? We all have felt the intense stress of having to empty our bladders and not knowing where the nearest restroom (or freeway exit) is. We also know how the bladder and bowels are affected by stress- how many times did you visit the port-a-potty before that last 5K run? As is the case with many conditions with which our patients present, we may not know if one started the other, and most likely, the combination of issues resulted in dysfunction. Regardless, in our pelvic rehabilitation practices we have the tools to help patients learn about their anatomy, physiology, power in healing, and skills to affect urinary urgency and frequency.

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The Role of the Pelvic Therapist in Treating Endometriosis

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy. She will be presenting this course this February!

 

Michelle Lyons

Endometriosis is a common gynaecological disorder, affecting up to 15% of women of reproductive age. Because endometriosis can only be diagnosed surgically, and also because some women with the disease experience relatively minor discomfort or symptoms, there is some controversy regarding the estimates of prevalence, with some authorities stating that as many as one and three women may have endometriosis (Eskenazi & Warner 1997)

 

There is a wide spectrum of symptoms of endometriosis, with little or no correlation between the acuteness of the disease and the severity of the symptoms (Oliver & Overton 2014). The most commonly reported symptoms are severe dysmenorrhoea and pelvic pain between periods. Dyspareunia, dyschezia and dysuria are also commonly seen. These pain symptoms can be severe and have been reported to lead to work absences by 82% of women, with an estimated cost in Europe of €30 billion per year (EST 2005). Secondary musculoskeletal impairments caused by may include: lumbar, sacroiliac, abdominal and pelvic floor pain, muscle spasms/ myofascial trigger points, connective tissue dysfunction, urinary urgency, scar tissue adhesion and sexual dysfunction (Troyer 2007) – all of which may be responsive to skilled pelvic rehab intervention.

 

Endometriosis can lead to inflammation, scar tissue and adhesion formation and myofascial dysfunction throughout the abdominal and pelvic regions. This can set up a painful cycle in the pelvic floor muscles secondary to the decrease in pelvic and abdominal organ/muscle/fascia mobility which can subsequently lead to decreased circulation, tight muscles, myofascial trigger points, connective tissue dysfunction and pain and possible neural irritation.

 

Abdominal trigger points and pain can be commonly seen after laparascopic surgery for diagnosis or treatment. We know that fascially, the abdominal muscles are closely connected with the pelvic floor muscles and dysfunction in one group may trigger dysfunction in the other, as well as causing associated stability, postural and dynamic stability issues.

 

The pain created by muscle tension and dysfunction, may lead to further pain and increasing central sensitisation and further disability. Unfortunately for the endometriosis patient, as well as dealing with the problems already associated with endometriosis, she may also develop a spectrum of secondary musculo-skeletal problems, including pelvic floor dysfunction – and for some patients this may actually be responsible for the majority of their pain (Troyer 2007).

 

The skilled pelvic rehab therapist has much to offer this under-served patient population in terms of reducing pain and dysfunction, educating regarding self-care and exercise and helping to restore quality of life. Interested in learning more? Join me for my new course: ‘Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy’ in San Diego this February or Chicago in June.

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The Role of the Pelvic Therapist in Treating Endometriosis

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy. She will be presenting this course this February!

Michelle Lyons

Endometriosis is a common gynaecological disorder, affecting up to 15% of women of reproductive age. Because endometriosis can only be diagnosed surgically, and also because some women with the disease experience relatively minor discomfort or symptoms, there is some controversy regarding the estimates of prevalence, with some authorities stating that as many as one and three women may have endometriosis (Eskenazi & Warner 1997)

There is a wide spectrum of symptoms of endometriosis, with little or no correlation between the acuteness of the disease and the severity of the symptoms (Oliver & Overton 2014). The most commonly reported symptoms are severe dysmenorrhoea and pelvic pain between periods. Dyspareunia, dyschezia and dysuria are also commonly seen. These pain symptoms can be severe and have been reported to lead to work absences by 82% of women, with an estimated cost in Europe of €30 billion per year (EST 2005). Secondary musculoskeletal impairments caused by may include: lumbar, sacroiliac, abdominal and pelvic floor pain, muscle spasms/ myofascial trigger points, connective tissue dysfunction, urinary urgency, scar tissue adhesion and sexual dysfunction (Troyer 2007) – all of which may be responsive to skilled pelvic rehab intervention.

Endometriosis can lead to inflammation, scar tissue and adhesion formation and myofascial dysfunction throughout the abdominal and pelvic regions. This can set up a painful cycle in the pelvic floor muscles secondary to the decrease in pelvic and abdominal organ/muscle/fascia mobility which can subsequently lead to decreased circulation, tight muscles, myofascial trigger points, connective tissue dysfunction and pain and possible neural irritation.

Abdominal trigger points and pain can be commonly seen after laparascopic surgery for diagnosis or treatment. We know that fascially, the abdominal muscles are closely connected with the pelvic floor muscles and dysfunction in one group may trigger dysfunction in the other, as well as causing associated stability, postural and dynamic stability issues.

The pain created by muscle tension and dysfunction, may lead to further pain and increasing central sensitisation and further disability. Unfortunately for the endometriosis patient, as well as dealing with the problems already associated with endometriosis, she may also develop a spectrum of secondary musculo-skeletal problems, including pelvic floor dysfunction – and for some patients this may actually be responsible for the majority of their pain (Troyer 2007).

The skilled pelvic rehab therapist has much to offer this under-served patient population in terms of reducing pain and dysfunction, educating regarding self-care and exercise and helping to restore quality of life. Interested in learning more? Join me for my new course: ‘Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy’ in San Diego this February or Chicago in June.

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Upcoming Continuing Education Courses

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (RESCHEDULED)

Jul 10, 2020 - Jul 12, 2020
Location: Virginia Hospital Center

Mobilization of Visceral Fascia: The Gastrointestinal System

Jul 10, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Short Form Remote Course

Athletes & Pelvic Rehabilitation - Remote Course

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Bowel Pathology and Function - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Newark, NJ (Rescheduled)

Jul 12, 2020 - Jul 14, 2020
Location: Rutgers University - Doctoral Programs in Physical Therapy

Pregnancy Rehabilitation - Remote Course

Jul 16, 2020 - Jul 17, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Foothill Ranch, CA (RESCHEDULED)

Jul 18, 2020 - Jul 19, 2020
Location: Intercore Physical Therapy

Pelvic Floor Level 1 - Colorado Springs, CO (SOLD OUT)

Jul 18, 2020 - Jul 19, 2020
Location: Manual Edge Physiotherapy

Postpartum Rehabilitation - Remote Course

Jul 18, 2020 - Jul 19, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1- Bangor, ME (Rescheduled)

Jul 18, 2020 - Jul 19, 2020
Location: Husson University

Pelvic Floor Level 1 - Columbus, OH

Jul 18, 2020 - Jul 19, 2020
Location: Fitness Matters

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 21, 2020 - Jul 22, 2020
Location: Short Form Remote Course

Nutrition Perspectives for the Pelvic Rehab Therapist - Columbia, MO (Rescheduled)

Jul 24, 2020 - Jul 26, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Chicago, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Advocate Illinois Masonic Medical Center

Pelvic Floor Level 1 - Fayetteville, NC (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Methodist University School of Health Sciences

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Jul 25, 2020 - Jul 26, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Glenwood Springs, CO (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Valley View Hospital

Pudendal Neuralgia and Nerve Entrapment - Maywood, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Loyola University Health System

Pelvic Floor Level 2B - Los Angeles, CA (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Mount Saint Mary’s University

Manual Therapy for the Abdominal Wall - Remote Course

Jul 31, 2020
Location: Short Form Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

Jul 31, 2020 - Aug 1, 2020
Location: Short Form Remote Course

Neurologic Conditions and Pelvic Floor Rehab - Washington, DC

Jul 31, 2020 - Aug 2, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Restorative Yoga for Physical Therapists - Remote Course

Aug 1, 2020 - Aug 2, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Chicago, IL (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: Midwestern Regional Medical Center

Pelvic Floor Level 2A - Washington, DC (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: The George Washington University

Pelvic Floor Level 1 - New York City, NY (RESCHEDULED)

Aug 2, 2020 - Aug 3, 2020
Location: Touro College

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Aug 8, 2020 - Aug 9, 2020
Location: Shelby Baptist Medical Center